Antibiotic Use Not all bugs need drugs

Antibiotics are clearly one of the most important discoveries of modern medicine. In the 60 years since they have been discovered, antibiotics have saved millions of lives. Unfortunately, some bacteria can no longer be killed by antibiotics. This antibiotic resistance is due to the ability of bacteria to change and adapt. The World Health Organization has called antibiotic resistance a global health crisis needing urgent solutions.

Half of the antibiotics used in the world today are used in humans. The rest are used in agriculture to treat and prevent infections in animals and plants. Agricultural use of antibiotics has been identified as one of the factors contributing to antibiotic resistance.

Overuse and inappropriate use of antibiotics in humans has been recognized as another major contributor to this problem. Of the antibiotics used in humans, 80 per cent are used to treat infections in the community. The rest are used for more serious infections in hospitals.

Most of these infections are respiratory tract infections occurring along the pathways taken by the air we breath. These tract infections include colds, flu, sore throats, ear infections, sinusitis, croup, laryngitis, bronchitis, bronchiolitis and pneumonia. Bronchitis is an infection in the breathing tubes in the lungs. Bronchiolitis is an infection in the tiny breathing tubes of a young child and it often causes wheezing.

Pneumonia is an infection deep in the lung where oxygen from the air reaches the blood. With the exception of pneumonia, most respiratory infections are due to viruses. Antibiotics do not work against viruses. Yet up to 75 per cent of antibiotics are used to treat respiratory tract infections. About one half of prescription antibiotics intended to treat respiratory tract infections are not necessary and can be harmful.

In 1997, the Canadian Committee on Antibiotic Resistance issued a mandate to decrease the use of antibiotics in respiratory tract infections by 25 per cent. Given the overuse of antibiotics, this would seem an achievable goal. Unfortunately there are some mistaken ideas that need to be resolved before antibiotic use can be curbed. For example, a survey done in February 2000 by the National Information Program on Antibiotics indicates that 54 per cent of adults in Canada believe antibiotics are effective against viruses.

Public pressure to receive antibiotics influences the over-prescribing of antibiotics. In a recent survey conducted in the Capital Health Region (Edmonton), 31 per cent of adults interviewed expect an antibiotic from their doctor when they have symptoms of a respiratory tract infection. If it is their child who has these symptoms, 35 per cent expect antibiotics. It is also a concern that 11 per cent of people interviewed would seek another doctor if an antibiotic prescription was not given by the first doctor.

Antibiotic Resistance

Using antibiotics when they are not needed can lead to antibiotic resistance. Bacteria can become resistant to the affects of the antibiotic. This is sometimes a difficult concept to understand, as people may believe that their immune system is making them resistant to antibiotics. In fact, this is not the case at all. Antibiotic resistance has nothing to do with a person’s immune system.

It is the bacteria that are resistant to antibiotics - not people. This means even very healthy people who have never taken antibiotics can be exposed to antibiotic resistant bacteria from others! These bacteria are sometimes resistant to many antibiotics, and there may not be any way to treat them.

The good news is antibiotic resistance can be reduced by using fewer antibiotics. Since most respiratory infections are due to viruses, the use of antibiotics in these infections could be drastically reduced.

Not All Bugs Are Created Equal

Both bacteria and viruses can cause infections of the respiratory tract. However, viruses cause most of these illnesses. Bacteria and viruses are very different types of germs. They are different in their structure, the way they cause infections and the ways they can be killed.

Antibiotics act in various ways to kill or control bacteria. Because of the big difference between bacteria and viruses, antibiotics do not work at all against viruses. In fact, giving antibiotics to someone who has a virus may actually be harmful. It exposes the bacteria in the body to antibiotics. This allows the bacteria the chance to develop resistance to the antibiotic. With time this ability to become resistant can be passed to the more serious disease-causing bacteria.

Rely on your doctor’s advice if an antibiotic is not prescribed for a respiratory illness.

Viruses

Viruses are more contagious than bacteria. If more than one person in the family has the same illness, odds are it is a viral illness. Colds, flu, croup, laryngitis, chest colds and most sore throats are due to viruses. Bronchitis is another name for a chest cold. In adults and children who otherwise have healthy lungs it is also due to viruses. It is one of the most common reasons why adults get antibiotics that are not needed.

Contrary to what many people believe, viruses can make a person just as sick, if not sicker, than a bacterial infection. This is especially true for the flu. Generally, a viral illness will last four to five days. However, it may take up to three weeks or more to feel completely better.

Bacteria

Bacterial infections are less common than viral infections and are less contagious. It is important to remember that pneumonia, the most serious respiratory tract infection, is usually caused by bacteria. Pneumonia can be a serious illness, sometimes resulting in death. The major reason for making sure antibiotics are used wisely is to ensure they still work for this, and other, potentially fatal illnesses.

The most common bacteria to cause pneumonia (Streptococcus pneumoniae) is now developing resistance. Antibiotics that would have worked very well several years ago are no longer effective!

When to Wash Your Hands

Before meals

Before feeding children, including breastfeeding

Before and after preparing food, especially raw meat, poultry or fish

After using the toilet, changing a diaper or helping a child use the toilet

After blowing your nose, coughing or sneezing

Before and after being with someone who is sick

Before and after treating a wound

Before inserting or removing contacts

After playing with toys shared with other children

After handling animals or pets or their waste

How to Wash Your Hands

Use soap and warm water.Water alone does not get rid of germs.

Rub hands together for 20 seconds, the time it takes to sing Twinkle Twinkle Little Star. Pay special attention to the fingertips and under the fingernails. Ninety-five per cent of germs are found under the fingernails.

Rinse hands for 10 seconds.

Dry hands completely. Use a clean, dry towel if possible.

Care must be taken, especially in public places, not to recontaminate the hands by touching dirty surfaces. After washing your hands in a public washroom, use paper towel to turn off the taps and open the door.

Hand Washing

Hand washing is the single most important way to stop the spread of infections. In fact, hands spread 80 per cent of the most common infections.

A single hand can harbour as many as 200 million organisms including bacteria, viruses and fungi. Most of the organisms on the skin are good bacteria, called resident flora. These bacteria protect from infection by crowding out bad bacteria and viruses. The bad germs, referred to as transient flora, can live on hands for short periods of time. They can cause infection when they enter the body, by the hands by touching mucous membranes like the mouth, nose or eyes.

Developing good hand washing habits will prevent many infections. This life skill should be taught to children early. The key is to make hand washing a habit rather than a chore. Germs are easily removed by proper hand washing with regular soap and water.

Antibacterial soap

There has been a trend in the last few years, to use antibacterial soap. These products are effective in killing the bacteria on the skin. The problem is they also kill the good bacteria that protect from the disease-causing bacteria and viruses. Repeated exposure of bacteria to these antibacterial products can make the bacteria resistant. This resistance can be transferred from the resident bacteria to some of the disease-causing transient bacteria.

There is no need to use antibacterial soaps in the home, school or workplace. Proper hand washing with regular soap and water can remove germs very effectively. Antibacterial soaps should be reserved for hospital settings (for example surgeons who are preparing for surgery).

Respiratory Tract Infections (RTI)

Here are descriptions of and treatment for some of the more common RTIs.

Fever

Fever is often a symptom that makes people worry and seek medical advice. A high fever is sometimes thought to mean a bacterial infection. This is not necessarily the case, as viral infections may also be associated with high fevers.

Fever, in fact, is one of the ways the body has to fight infection, and is usually helpful. Fever occurs with most respiratory tract infections, both viral and bacterial. Acetaminophen or ibuprofen may help to relieve a fever. Do not give children under the age of 18 years drugs that contain acetylsalicylic acid (e.g. ASA, Aspirin™) due to the risk of Reye’s syndrome which causes damage to the liver and brain.

When a fever is reduced in a child with a viral infection, the child usually feels better. In a child with a bacterial infection, especially pneumonia, the child will usually still feel miserable, even when the temperature is brought down.

Colds

There are about 200 different viruses that cause colds. On average, children get eight to 10 colds per year. Adults get fewer colds. This is mostly because they have built up immunity against some of the cold viruses to which they have been previously exposed.

Most colds bring a cough or a sore throat. When a person has the other familiar symptoms of a cold (runny nose, irritated eyes), the cough and sore throat are also due to the virus and do not need further investigation or an antibiotic. A yellow or green discharge from the nose is one of the most common reasons people receive antibiotics for colds. Yet this is the normal progress of a cold - not a new bacterial infection. The change in colour shows that the immune system is in full gear to fight the virus. It means that the body has mobilized some of its infection fighting cells (mostly white blood cells).

Colds usually last four to five days but it may take up to three weeks or more to feel completely better. The best treatment for colds is fluids, especially warm fluids, rest and acetaminophen or ibuprofen for fever. Cough suppressants, such as dextromethorphan (DM), may help to relieve a cough.

Salt water nose drops are especially useful for babies and toddlers to relieve nasal congestion.

Flu

The flu (influenza) is caused by a virus. The flu season starts in November or December and ends in April or May. The flu can make a person very sick with fever, chills, muscle and body aches, sore throat and cough. It typically lasts four to five days but it may take three weeks or more to feel completely better.

The best way to prevent the flu is to get a yearly flu vaccine. The vaccine is about 70 per cent effective in preventing the flu. Because the flu virus is always changing, it is necessary to get a new vaccine every year.

If a person has the flu, the best way to prevent the spread of the virus is regular hand washing. As well, a tissue should be used for blowing the nose, and coughing or sneezing on anyone should be avoided. In the first few days of illness it is important for the sick person to stay away from school or work to prevent spreading the virus. Adults spread the virus for three to five days after first feeling sick, while children can spread the virus for up to one week.

There are new drugs available called antivirals that can work against the flu virus. These drugs must be taken within the first 48 hours of the flu symptoms to be effective. The problem is this is often when people are not sure they have the flu. The best treatment for the flu is fluids, rest and acetaminophen or ibuprofen for the fever, aches and pains. Cough suppressants, such as dextromethorphan (DM), may help to relieve a cough.

Sore throats

Most sore throats are symptoms of colds or the flu. These do not require further investigation and will not be helped by an antibiotic. About 15 per cent of sore throats are due to bacteria called Streptococcus pyogenes (Group A Strep). This is referred to as Strep throat. Although it may occur in adults, this infection affects mainly school-aged children between the ages of five and 10. Strep throat is more common in the fall and winter.

Unfortunately, it is not possible to tell just by looking whether a sore throat is due to a virus or bacteria. A throat swab must be taken. It usually takes 48 hours to get a result. If the result is positive, penicillin will usually be prescribed for the Strep throat. Antibiotics do not greatly decrease the symptoms of a sore throat. However, they help prevent complications that can occur after having an infection with Streptococcus bacteria. If the swab result is negative, it means this is probably a viral infection and antibiotics will not help. While waiting for the results, acetaminophen or ibuprofen should be given for pain and fever.

A throat swab is only necessary if a person has a sore throat and no other symptoms. People with cold symptoms and a sore throat may show Streptococcus bacteria on a throat swab, but in fact the symptoms are due to a virus. This is because healthy people can carry Streptococcus bacteria in their throat with no symptoms. For these people, a swab may falsely show Strep throat and antibiotics may be prescribed inappropriately.

A sore throat associated with a cold or the flu does not need a throat swab or an antibiotic.

Ear infections

Ear infections are one of the most common reasons why children are prescribed antibiotics. Young children are more prone to ear infections. This is because the eustachian tube that connects the ear to the throat can easily become blocked during a cold. This blockage can lead to a bacterial infection in the ear.

Not all earaches are due to a bacterial infection. During a viral infection, fluid may build up in the ear causing pain. Redness inside the ears is often seen in children who are sick and have been crying. This is also not a reason to give antibiotics. Fluid behind the eardrum is a common reason for the misuse of antibiotics. This is very common after a cold or a bacterial ear infection. In fact, half of children still have fluid behind the eardrum one month after appropriate treatment with antibiotics. If the child’s symptoms have improved, there is no reason to give more antibiotics. Children with an ear infection should be examined after three months. At this time all the fluid should be gone. If it is not, this might lead to hearing problems!

Some children have many ear infections over a short period of time. These children might benefit from having small tubes (myringotomy) put in their ears surgically. Because of the problem with antibiotic resistance, it is not recommended to give antibiotics on a regular basis for long periods to prevent further infections.
At all times children with earaches should be given adequate pain medicine (acetaminophen, ibuprofen).

Sinus infections

The sinuses are air-filled spaces around the nose and the eyes. Sinusitis is an inflammation of these sinuses and can occur when fluid builds up in this area. Both bacteria and viruses can cause sinusitis, but viruses are up to 200 times more common.

Sinusitis most often occurs after a cold, but most colds do not lead to sinusitis. The symptoms of sinusitis are more severe and last longer than a cold. A yellow or green runny nose within a few days of a cold is normal. If this discharge continues for more than 10 days, this may be a sign of bacterial sinusitis.

Unfortunately, sinus x-rays are not helpful in diagnosing bacterial sinusitis. X-rays cannot tell the difference between the fluid that builds-up with a viral infection and the problems of a bacterial infection.

Decongestants may help to relieve symptoms but do not shorten the illness. If cold symptoms reoccur and are associated with a clear discharge, this indicates another cold, not sinusitis.

Coughs

The majority of coughs in otherwise healthy children and adults are due to viruses. Bronchitis, often called a chest cold, occurs when the lining of the bronchi (the large airways that go to the lungs) become inflamed. In people with chronic lung diseases, bronchitis may sometimes be due to bacterial infections.

Many people put up with a cough for a few days but often seek medical advice if they start coughing up yellow or green sputum or if the cough is prolonged. Like the yellow or green runny nose of a cold, the discoloured sputum associated with bronchitis shows that the body is fighting the infection. It does not mean it is a bacterial infection.

It is important to be patient with a cough. Viral infections can cause a lot of irritation to the lining of the airways, resulting in discomfort and coughing. However, some coughs are associated with pneumonia. Pneumonia is a serious infection of the lungs which may also be caused by bacteria. These people are usually much sicker and often have had their symptoms for a shorter time. If pneumonia is suspected, a chest x-ray should be done to confirm the diagnosis. Antibiotics are usually prescribed.

Forty-five percent of people with bronchitis still have a cough two weeks after the start of their symptoms. At three weeks, 25 per cent still have a cough. Cough suppressants, such as dextromethorphan (DM), may help to relieve a cough.

Resources

Not All Bugs Need Drugs

Respiratory tract infections are the most common infections for which antibiotics are prescribed. Many of these antibiotics are not necessary as the majority of these infections are due to viruses.

Giving antibiotics for viral infections adds to the problem of antibiotic resistance. Most respiratory tract infections will get better with fluids and rest. Pneumonia is the one respiratory infection where antibiotics can make a difference.

Get tough on germs; wash your hands! Hand washing with regular soap is the best way to stop the spread of respiratory infections. This simple habit may be the most important key to reduce the use of antibiotics and ensure that antibiotics continue to save lives in the future.